Nursing Care Plan

Topics: Nursing care plan, Nursing, Blood pressure Pages: 14 (1756 words) Published: April 6, 2015


NURSING CARE PLAN

Nursing Assessment:
Ms. F.E. is a 20yr. old female who was involved in a motor vehicle accident (M.V.A.), and was admitted on 04.03.12 to the surgical unit with Spinal injuries, Polytrauma and fractured right humerus. She started complaining of severe abdominal pains, one week after assessment by Doctor, she was scheduled for emergency laparotomy with ?diagnosis Perforated Hallow Viscus. Following surgery patient was diagnosed with Fecal Peritonitis and was transferred to the Intensive Care Unit (I.C.U.), because her condition became critical. On 16.03.12, patient was scheduled for another laparotomy, for abdominal toileting and colostomy. Two chest tubes drains were left insitu in a paracolic area. Patient has nasogastric tube insitu for continuous drainage. Foley’s catheter is insitu on continuous drainage. IV fluids DNS 166mls/hr in progress via left hand. Patient is conscious, but is maintained on mechanical ventilator and attached to cardiac monitor. On 17.03.12 patient was extubated, but remained on continuous humidified O2 at 10L/min via facemask.

Physical Examination
T- 39.3 OC Skin: pale and moist
P- 150 bpm Pupils: 2/2
R- 15 bpm Reaction- RTL
B/P- 107/43 mmHgRBS- 101mg/dl
Midline abdominal incision, sutures dry and intact
diagnostic Data
X-ray- chest, pelvic and spine
MRI
Electrolytes
Direct Bilirubin
Albumin
BUN Creatinine
DAY ONE 16-03-12: Patient is still intubated but is conscious and oriented

aSSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ Planning
Intervention
Evaluation
Subjective Data:
Patient indicated using her hands to signal that she in pain.

Objective Data:
Patient’s blood pressure increased,
Pulse rate increased. Patient’s facial expression showed that she’s in discomfort. Alteration in comfort: Pain related to trauma manifested by patient moaning and expressing discomfort and increased pulse and blood pressure Patient will experienced relief of pain as evidenced by:

- expressing relief using hand signs

- a change in the pulse and blood pressure ( within normal range)

- patient will be able to rest comfortable without discomfort

1. A comprehensive assessment of the patient’s pain was made which includes: location, severity on a scale of 1-10, duration, quality and precipitating factors of pain.

2. Reduce or eliminate factors that precipitate or increase the patient’s pain experience (e.g. fear, fatigue and lack of knowledge).

3. Patient was positioned properly to reduce discomfort caused by pain.

4. Simple relaxation therapies were used (e.g. music therapy, peaceful imaging and massage) before, after and if possible during certain procedures; before pain occurs or increases; and along with other pain relief measures.

5. Ms. F.E. was provided with optimal pain relief with prescribed analgesic.

6. Patient’s response to nursing interventions were documented.

The outcomes were partially met. The patient expressed pain and discomfort by showing hand signs or signals when she’s starting to experience pain during a procedure. Ms. F.E. uses her fingers to show if the pain is a 2 or 7 (on a scale of 1-10) before the administration of analgesics and 30 mins. following administration. Ms. F.E. is willing to try relaxing techniques; however because of the workload in I.C.U. this is not always done.

ASSESSMENT
Nursing Diagnosis
Outcome IDENTIFICATION/ Planning
Intervention
Evaluation
Subjective Data:
Patient indicates that she’s uncomfortable and would like to be tidied.

Objective Data:
Patient’s facial expression showed signs of discomfort.

Self-care Deficit:
Bathing and Hygiene related to Polytrauma, fractured humerus, spinal cord injury and post operative wound as manifested by limited range of motion Patient will:
1. Be able to assist in their self care.

2. Be able to express herself through signs and lip movements

3. Feel clean, tidy and...
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